Technical Reports

A Novel Technique for Fundal Retraction

of the Gallbladder in Single-Port Cholecystectomy
Joachim Reibetanz, MD, Alexander Wierlemann, MD,
Christoph-Thomas Germer, MD, and Katica Krajinovic, MD
Abstract
Recent reports on the feasibility and safety of single-incision cholecystectomy have challenged the conventional
multiport access to the gallbladder. Nevertheless, the proximity of different instruments and the laparoscope
may lead to interference that potentially compromises the safety of the operation. This article describes the use of
a customary exible restraint system for the gallbladder fundus to achieve triangulation by means of a three-
instrument technique and an optimized view to the Calots triangle.
Introduction
S
ingle-incision cholecystectomy displays substantial
progress in minimally invasive surgery, and recent re-
ports on the feasibility of this novel technique have challenged
the conventional multiport laparoscopic technique as the gold
standard in cholecystectomy.
13
Nevertheless, one major
drawback of single-incision surgery is the proximity of dif-
ferent instruments and the laparoscope inserted via the same
port, resulting in extracorporeal interference, which poten-
tially compromises the safety of the operation. Concerning
safety aspects, an independent retraction technique of the
gallbladder fundus is crucial for an optimal exposition of
critical structures in the Calots triangle.
4
This technique
should also offer maximum range of motion for the applied
instruments during preparation.
We describe a new technique of independent fundal re-
traction of the gallbladder using a thin and space-saving
customary restraint system.
Operative Technique
The articulated restraint system (DB
2
C; Chirurgical Con-
cept, Mery-sur-Cher, France) and its connection to the left
side of the operation table are shown in Figure 1. The retractor
is rigid at its back end, and at its front end it is tridi-
mensionally exible and lockable in any position. The con-
nection of the retractor to a straight 3-mm grasper used for
gallbladder fundal retraction is shown in Figure 2.
Single-port access cholecystectomy is performed using
the re-usable X-Cone Single-Port Laparoscopic Device (X-
Cone
TM
; Karl Storz GmbH, Tuttlingen, Germany) (Fig. 3).
This metal device is composed of two tapered L-shaped half
shells (one with an insufation tap) and sealed with a silicone
rubber cap. After a 20-mm vertical skin incision in the umbi-
licus, via an open approach, the port is trocar-like placed into
the abdominal cavity, creating an autostatic X-shaped funnel.
For sealing, a rubber cap offering ve gas-proof working
channels is applied. One of the ve working channels permits
the introduction of instruments up to 12.5 mm. A 50-cm-long,
30, 5-mm laparoscopic camera (Karl Storz) is introduced via
the right working channel. After the gallbladder is identied,
attention is directed to the gallbladder fundus, which is re-
tracted upward using a straight 3-mmgrasper inserted via the
lowest working channel. This technique is comparable to
fundal exposition known from standard multiport cholecys-
tectomy. For a static fundal retraction, the hand grip of the
grasper is then connected to the exible retractor and the re-
tractor is locked in this position (Fig. 4). For infundibular
manipulation, a curved roticulating grasper (Karl Storz) is
used, placed via the left working channel. Independent fundal
retraction combined with the roticulating function of the
curved (infundibular) grasper enables perpendicular distrac-
tion of the cystic duct from the common bile duct and an
optimal exposition of the anterior and dorsolateral view to
the Calots triangle (Figs. 5 and 6). For dissection and isolation
of the cystic duct and the cystic artery, a 5-mm scissors
(Karl Storz) is used. The cystic duct and the cystic artery are
doubly clipped using a 10-mm clip applicator (Challenger
Ti
TM
; Aesculap AG, Tuttlingen, Germany) inserted via the
middle working channel, and then transected. During these
procedures the fundus is statically retracted with the 3-mm
grasper. Besides optimal exposure, this technique offers
Department of General, Visceral, Vascular, and Pediatric Surgery, University Hospital of Wuerzburg, Wuerzburg, Germany.
JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
Volume 21, Number 5, 2011
Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2010.0487
427
maximum range of motion for the additionally inserted in-
struments, minimizing extracorporeal conicts of the hands.
Further, the assistant can use both hands for optimal camera
work, including radial work with the light cord (Fig. 7). For
dissection of the gallbladder from the liver bed, the restraint
system may be removed and the 3-mm grasper managed by
the surgical assistant. After complete dissection, the gall-
bladder is placed in an endobag (Inzii
TM
; Applied Medical,
Rancho Santa Margarita, CA) and removed at the port site.
The fascial defect at the umbilicus is then closed using inter-
rupted absorbable sutures (Vicryl 0; Ethicon GmbH, Nor-
derstedt, Germany), and the skin incision is closed with a 4-0
absorbable subcuticular suture.
Discussion
With the development of single-port cholecystectomy as
a less invasive access to the gallbladder, surgeons were
forced to become familiar with in-line viewing and a lim-
ited ability of triangulation, both resulting in a potentially
compromised view to critical structures in the Calots tri-
angle. Given the different techniques that have evolved in
single-port surgery (with versus those without an access
device), the use of an access device itself may limit the
range of instrument motion, as all instruments need to be
passed through the bottleneck of the port. Using the X-
Cone, we experienced that this drawback (of any access
device) is outweighed by the stable instrument guidance
and the gas-tight sealing.
In a recent report, Podolsky and Curcillo clearly demon-
strated the superiority of a three-instrument technique in
achieving and maintaining an optimal exposure of the hepa-
tocystic triangle, when compared with 2-instrument use.
4
However, increasing the number of instruments inserted via a
single incision (in the umbilicus) again connes the ability of
unhindered instrument motion. This problem may even in-
crease when using an access device, as mentioned above.
Consequently, attempts have been made to avoid collision of
instruments (and the laparoscope) while achieving the best op-
erative exposure, including instruments of different lengths,
articulated instruments, exible-tip cameras, transperitoneal
sutures, or magnetic aid.
5,6
Nevertheless, some of the reported
techniques
6
raise concerns regarding bile spillage.
7
The use of a thin, lockable retraction system for the gall-
bladder fundus enables (1) good triangulation by means of a
three-instrument technique, (2) an increased range of instru-
ment motion for the surgeon by eliminating one of the assis-
tants hands from the limited area of the external instrument
handles, and (3) superior camera work afforded by use of both
of the assistants hands. A safe anterior and dorsolateral view
of the hepatocystic triangle was achieved by the roticulating
function of the curved grasper. Further, we were able to
FIG. 1. Restraint system (DB
2
C; Chirurgical Concept) for
gallbladder fundus retraction, xed to the left side of the
operation table.
FIG. 2. Connection of the restraint system to the hand grip
of the 3-mm grasper.
FIG. 3. Reusable X-Cone
TM
Single-Port Laparoscopic
Device (Karl Storz).
FIG. 4. Three-millimeter grasper, inserted via the lowest
working channel, connected to the restraint system for static
gallbladder fundus retraction.
428 REIBETANZ ET AL.
largely use customary equipment for conventional multiport
cholecystectomy. The re-usability of the retractor and its
connectability to the hand grip of a standard 3-mmgrasper do
not increase costs of the procedure. Finally, the restraint sys-
tem introduced here is not prerequisite when using the X-
Cone device but has emerged as a practical additional tool in
recent single-port cholecystectomies performed by our group.
We anticipate that this might also apply for other single-port
access techniques.
Acknowledgment
We thank A. Kellersmann and H. Bergauer for technical
assistance with the graphical material.
Disclosure Statement
K. Krajinovic and C.-T. Germer received travel grants from
Karl Storz. For J. Reibetanz and A. Wierlemann, no competing
nancial interests exist.
References
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)
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Address correspondence to:
Joachim Reibetanz, MD
Department of General, Visceral,
Vascular, and Pediatric Surgery
University Hospital of Wuerzburg
Zentrum Operative Medizin
Oberduerrbacher Str. 6
97080 Wuerzburg
Germany
E-mail: reibetanz_j@chirurgie.uni-wuerzburg.de
FIG. 5. Exposition of the gallbladder infundibulum in a
three-instrument technique (anterior view).
FIG. 6. Exposition of the gallbladder infundibulum in a
three-instrument technique (dorsolateral view).
FIG. 7. Optimal extracorporeal range of motion for the
applied instruments. The assistant can use the free left hand
(*) for radial work with the light cord.
FUNDAL RETRACTION IN SINGLE-PORT CHOLECYSTECTOMY 429
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